Laserfiche WebLink
,'Mai, 13 05.11:,27a Fisch Drilling 209-772-3571 p.2 <br />FRO11 Ground Zero analysts PHONE N0. : 209 838 9883 h1ay. 13 2005 10:14AM P3 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 2360 East Street, Tracy, CA PERMIT SR#: Z�z3 <br />LICENSED CONTRACTORS DECLARATION (LCC) <br />I hereby affirm that t am licensed under the provisions of Chapter 8 (commencing with Section 7000) of Division <br />3 of the Business and /Professions Code and my license is in full force and effect. <br />License: L� A c �lJ J Expiration Date: _0 ( <br />Date �� �S Contractor� ResCk-�- <br />Signature: <br />Printed name: d_ 't 5c44- <br />Title: 0 W IiJe 2 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self -insure for workers' compensalion, as provided for by <br />Section 3700 of the Labor Code, for the perforrnanc8 of the work for which this permit is issued. <br />IV t have and will maintain workers' compensation insurance, as required by Section 3700 cf the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and licy rube' 1, are: <br />carrier. � 6�1( Policy Number: <br />certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' mm ensaticn provisions of Section 3700 of the Labor Code, 1641 <br />forthwith comply with those provisions. <br />Date.. `� Signature,- <br />Printed <br />ignature_Printed Name: �J✓�L S ��/ <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(f117Q,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SE <br />S 3706 OF THE LABOR CODE. <br />_ (signature ofC-57 licensed authorized representattve), <br />hereby authorize (print name) J hn P. Lank, Ground Zero Analysis _ <br />to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authortzathon is valid for <br />one (1) year and la limited to the work plan dated on the front page of this application. <br />I MI <br />